• Dissemination—Deploy knowledge and tools to clinicians and patients.

ADVERSE EVENT ANALYSIS

The Institute of Medicine’s (IOM) report To Err Is Human: Building a Safer Health System report (Institute of Medicine, 2000) boosted existing patient safety initiatives and stimulated new ones. Today in the United States, there are many types of patient safety reporting systems in operation or under development at the federal, state, and private-sector levels. Overseas, Australia (Australian Council for Safety and Quality in Health Care, 2001; Runciman and Moller, 2001) and the United Kingdom (National Patient Safety Agency, 2001) are implementing nationwide patient safety reporting systems.

The federal government operates patient safety reporting systems as part of its role of performing regulatory oversight of the health care industry and as part of its caregiver role through the Veterans Health Administration and the Department of Defense. Many states operate reporting systems as part of their regulatory oversight role of health care providers. In addition, many health care institutions operate patient safety systems for internal quality improvement purposes, and a few private-sector organizations operate such systems on a national basis. Appendix C provides summaries of a sampling of major U.S. patient safety reporting systems.

The aim of adverse event analysis is to identify ways to improve the delivery of health care through the analysis of adverse events. Accomplishing this objective involves defining the adverse events to investigate, establishing methods for the detection of such events, and identifying the data needed for analysis purposes. The functional requirements of adverse event analysis systems and the implications for data standards are examined in Chapter 6.

NEAR-MISS ANALYSIS

Current patient safety reporting systems are nearly always focused on adverse events and usually neglect near-misses (sometimes called “close calls”). Of the patient safety reporting systems currently operational in the United States, only a small proportion collect and analyze information on near misses (see Appendix C). None of the reporting systems used for federal regulatory oversight include near misses as reportable events. Of the 21 states mandating patient safety reporting systems, only Pennsylvania and



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